Reducing Risk in Vascular Access: A Review of Best Practice Timothy R. Spencer, RN, APN, DipAppSci, Bach.Health, ICCert, VA-BC
Why are we here tonight?
Majority of CLABSI occurs outside the ICU Central Venous CRBSIs 300,000 250,000 200,000 150,000 100,000 50,000 0 Annual Central Venous CRBSIs (n=250,000) 1 70% 30% 170,000 80,000 Infections Non-ICU Patients ICU Patients A significant opportunity exists to reduce CRBSI incidence in non-icu settings. 1,2 1. Mermel L, Farr B, Sheretz R. Guidelines for the management of intravascular catheter-related infections. Clinical Infectious Diseases. 2001;32:1249-1272. 2. Strategies to Prevent Central Line Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update. Infection Control and Hospital Epidemiology. electronically published June 9, 2014. http://www.jstor.org/stable/10.1086/676533
Strategies to Prevent Central Line Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their central line associated bloodstream infection (CLABSI) prevention efforts. This document updates Strategies to Prevent Central Line Associated Bloodstream Infections in Acute Care Hospitals, originally published in 2008*. Jonas Marschall, Leonard A. Mermel, Mohamad Fakih, Lynn Hadaway, Alexander Kallen, Naomi P. O Grady, Ann Marie Pettis, Mark E. Rupp, Thomas Sandora, Lisa L. Maragakis and Deborah S. Yokoe (2014). Strategies to Prevent Central Line Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update. Infection Control & Hospital Epidemiology, 35, pp 753-771 doi:10.1086/501565
Independent risk factors for CLABSI 1. Prolonged hospitalization before catheterization 2. Prolonged duration of catheterization 3. Heavy microbial colonization at the insertion site 4. Heavy microbial colonization of the catheter hub 5. High internal jugular catheterization 6. Femoral catheterization in adults 7. Neutropenia 8. Prematurity (i.e. early gestational age) 9. Reduced nurse-to-patient ratio in the ICU 10. Total parenteral nutrition 11. Substandard catheter care 12. Transfusion of blood products (in children)
Evidence Based Prevention Practices to Prevent CLABSI In 2009 alone, an estimated 25,000 fewer CLABSIs occurred in U.S. ICUs than in 2001, a 58% reduction. This represents up to 6,000 lives saved and $414 million in potential excess health-care costs in 2009 and approximately $1.8 billion in cumulative excess health-care costs since 2001. A substantial number of CLABSIs continue to occur, especially in outpatient hemodialysis centers and inpatient wards.
Australian CLABSI Data ~2008 At a rate of 23 per 1000 catheter days It has an 11% mortality rate = 392 deaths PA in Australia from a preventable adverse event- Cost of CRBSI in Australia is estimated to be between $25.7 million AUD & $95.3 million pa. Casey, A. L, Mermel L. A, et al (2008) The Lancet Infectious Diseases, 8 (12): 763-776. Bolz et al (2008) Management of CVCs in ICUs in Australia Healthcare Infection 13:48-55
Australian CLABSI Surveillance In 2008, the Australian Commission on Safety and Quality in Healthcare (ACSQHC) recommended and endorsed a mandatory continuous national surveillance to collect and report on an agreed minimum dataset for central line associated blood stream infections in all ICUs. In early 2010, the Australian and New Zealand Intensive Care Society (ANZICS) initiated the ANZICS CLABSI Prevention Project.
Australian CLABSI Data ~2010 NSW CLAB-ICU Project (38 ICUs >15 months of data): CLABSI rate decreased from 3 to 1.2 per 1,000 line days. Perth: (all WA public ICUs): CLABSI rate (2009-2010): 0.55/1,000 linedays. Victoria: Since 2003, CLABSI surveillance had been coordinated by the Victorian Healthcare Associated Infection Surveillance System (VicNISS; 36 ICUs). Adelaide: (Feb 2012): 12 ICUs. No specific CLABSI surveillance. New South Wales (April 2012): Only private hospitals invited to the meeting - 3/16 ICUs attended. Queensland (May 2012): No CLABSI surveillance had been performed in ICUs. http://www.clabsi.com.au/useful-links
Lots of guidelines!
Guidelines CDC HICPAC 2011 Guideline http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf
CDC major emphasis areas are; 1. Education and training healthcare personnel who insert and maintain catheters 2. Using maximal sterile barrier precautions during central venous catheter (CVC) insertion 3. Using a >0.5% chlorhexidine (CHG) preparation with 70% alcohol for skin antisepsis 4. Avoiding routine replacement of CVCs as a strategy to prevent infection
CDC major emphasis areas are; 5. Using antiseptic/antibiotic impregnated short-term CVCs and chlorhexidine impregnated-style dressings, if the rate of infection is not decreasing despite adherence to other strategies; (i.e. education and training, maximum barrier precautions, and >0.5% CHG preparations with alcohol for skin antisepsis) 6. Performance improvement by implementing bundled strategies, and documenting and reporting rates of compliance with all components of the bundle as benchmarks for quality assurance and performance improvement.
Australian Guidelines
Australian Guidelines
Australian Guidelines; Australian Commission on Safety and Quality in Healthcare (ACSQHC), Australian Guidelines for the Prevention and Control of Infection in Healthcare, 2012: There is strong evidence (Grade B) that the use of chlorhexidine-impregnated (CHG) sponges at the catheter insertion site significantly reduces IVD-related bloodstream infections and device colonisation rates compared to other types of dressings for peripheral arterial devices, short-term or long-term central venous devices. Standard 3: Preventing and Controlling Healthcare Associated Infections.
SHEA Guideline Society for Hospital Epidemiology of America (SHEA) Infectious Diseases Society of America (IDSA) American Hospital Association (AHA) Association for Professionals in Infection Control and Epidemiology (APIC) The Joint Commission
SHEA Level of Evidence http://journals.cambridge.org/abstract_s0195941700093528
SHEA recommendations Basic Practices Catheter Checklist - II Hand Hygiene - II Insertion site - Femoral - I Cart Kit - II Maximal Barrier Precautions - I Chlorhexidine (CHG) Skin Prep - I Scrub the Hub I Special Approaches CHG Baths (ICU patients) - I Impregnated Catheters - I CHG Impregnated Disc - I Antimicrobial Locks - I Catheter Insertion Bundle Catheter Maintenance Bundle http://journals.cambridge.org/abstract_s0195941700093528
Factors Known To Influence CLABSI Rates Types of patients with catheters (gastrointestinal, neonatal, cancer, immunedeficient, ICU); Type, number, site of insertion, and duration of catheters (impregnated or not, number of lumens); Types of connectors (needleless split septum vs. mechanical valve, stopcocks; What is infused through the catheter (esp., blood, lipid, TPN); Who inserts/manipulates the catheter (IV team or not); Method of documenting BSI (central line cultures number of lumens and number of catheters cultured, only peripheral culture); Interpretation and application of the CDC or other CLABSI definitions and protocols; Infection control practices, hand hygiene, etc.
5 Evidence Based Strategies to Prevent CLABSI Prevention of CLBSI revolves around 5 best practices. When these interventions are bundled together, they significantly decrease CLBSI. These practices are: 1. Good Hand Hygiene 2. Use of Maximal Barrier Precautions For Catheter Insertion 3. Use of Chlorhexidine & Alcohol to Prepare Skin 4. Optimal Catheter Site Selection, with Avoidance of the Femoral Vein for Central Venous Access in Adult Patients 5. Daily Surveillance of Lines with Prompt Removal of Unnecessary Catheters Warren et al. ICHE 2006:27;662-7 Marschall et al. ICHE 2008:29; 22S-30S
New to the INS Standards in 2016 Infusion Team (I, IV, V) education, training and competency Standard Precautions (III-V) regulatory requirements Vascular Visualization (I-V) US/nIR technologies Central Vascular Access Device Tip Location (II, IV, V) ECG/EKG Nerve Injury (I A/P, IV, V) clear documentation of avoidable sites
The bacterial route of all evil Extraluminal 70%* Intraluminal 20-30%*
The Impact of Hand Hygiene 2014 (AU) Compliance Rate Overall Compliance Rate by Moment http://www.hha.org.au/latestnationaldata.aspx
Australasian Legal Information Institute Joint facility of UTS and UNSW Faculties of Law New South Wales Consolidated Regulations (Jan 2010) HEALTH PRACTITIONER REGULATION (NEW SOUTH WALES) REGULATION 2010 - SCHEDULE 1 Infection control standard Part 2 - General standards applying to relevant health practitioners 2 General precautions and aseptic techniques (1) Precautions must be taken to avoid direct exposure to a patient s blood or body substance. (2) The requirement in subclause (1) applies regardless of whether there is any perceived risk of infection. (3) Aseptic techniques must be used in the course of complying with the requirements of this Schedule. http://www5.austlii.edu.au/au/legis/nsw/consol_reg/hprswr2010580/sch1.html
CHG/Alcohol Skin Prep Is Best Skin prep with CHG/alcohol is more effective than with povidone iodine (Betadine) in preventing CLABSI This meta-analysis found that use of CHG reduced the risk of CLABSI by 49% Chaiyakunapruk N et al. Ann Intern Med. 2002;136:792-801
Skin Antisepsis adults and 2 months + Use an alcoholic chlorhexidine antiseptic for skin preparation (quality of evidence: I) Bathe ICU patients over 2 months of age with a chlorhexidine preparation on a daily basis (quality of evidence: I) In long-term acute care hospitals, daily chlorhexidine bathing may also be considered as a preventive measure * The role of chlorhexidine bathing in non-icu patients remains to be determined # * Munoz-Price LS Infect Control Hosp Epidemiol 2009;30(11):1031 1035. # Medina A J Nurs Care Qual 2014;29(2):133 140.
Skin Antisepsis: under 2 months The optimal choice of antiseptic agents is unresolved for children under 2 months of age. However, chlorhexidine is widely used in children under 2 months of age * FDA recommends use with care in premature infants or infants under 2 months of age; these products may cause irritation or chemical burns. Some institutions have used chlorhexidine-containing sponge dressings for CVCs $ and chlorhexidine for cleaning CVC insertion sites in children in this age group with minimal risk of such reactions # * Tamma PD et al Infect Control Hosp Epidemiol 2010;31(8):846 849. $ Curry S Neonatal Netw 2009;28(3):151 155. # Huang EY J Pediatr Surg 2011;46(10):2000 2011.
CHG Resistance Widespread use of chlorhexidine-based products (eg, use of chlorhexidine bathing, antisepsis, and dressings) may promote reduced chlorhexidine susceptibility in bacterial strains * However, testing for chlorhexidine susceptibility is not standardized. The clinical impact of reduced chlorhexidine susceptibility in gram-negative bacteria is unknown The benefits of chlorhexidine outweigh the risks of not using it. * Batra R Clin Infect Dis 2010;50(2):210 217
CHG Allergy CHG impregnated CVCs are widely used, because CHG 2% has demonstrated to reduce significantly intravascular catheter-related infections [Maki 1991], but CHG-coated CVC may be an important unrecognized source of CHG exposure. Importantly, CHG is not documented as a drug administered by anaesthesiologists because skin disinfection and catheter insertion performed by nurse staffs are considered as routinely preoperative activities. Contemporary double exposure to CHG-coated catheters may be possible: through central venous line plus the urethral pathway in ICU and OT. Always have non-chg impregnated devices and skin antiseptics available for patients with known or suspected CHG Ax.
Maximal Barrier Precautions
This picture does NOT show Maximal Barrier Protection
Maximal Barrier Precautions Data Maximum barrier precautions - the drape covers the patient from head to foot 3 studies: 1) Mermel 1991 Am J Med 91(3B):197S-205S. Prospective, Crosssectional Study (Swan-Ganz Catheters) demonstrated that the risk of infection was 2.2 fold higher when MBP were not used (p=0.03) 2) Raad 1994 Infect Control Hosp Epidemiol 15:231-8. Prospective, Randomized Study (Central Venous Catheters) demonstrated that the risk of infection was 3.3 fold higher when MBP were not used (p=0.03) 3) Lee 2008 Infect Control Hosp Epidemiol 2008;29:947-950 demonstrated that the risk for infection was 5.2 higher when MBP were not used (p=0.02)
Maximal Barrier Precautions Operator & supervisor (or anyone at risk for crossing the sterile field) Hand hygiene Non-sterile cap and mask All hair should be under cap (includes beard and mustache) Mask should cover nose and mouth tightly Sterile gown Sterile gloves For the Patient Cover patient s head and body with a large sterile drape For the Assistant (if required) Hand hygiene Non-sterile cap and mask All hair should be under cap (includes beard and mustache) Mask should cover nose and mouth tightly Sterile gown Sterile gloves Note: people in the same room who are not involved with the procedure (and who are not at risk for crossing the sterile field) do not need to wear maximal barrier precautions but cap and mask is required
Two-Dimensional Ultrasound (US) (Note: This picture shows assistants without the best practice PPE, consisting of cap, mask with eye protection and gown (within operating field)
US-guided versus Anatomical Landmark Meta-analysis of 18 RCTs Failed placement: RR 86% Complications: RR 57% First attempt failure: RR 41% Attempts: 1.5 Time: 69.3( sec) Keenan SP. Use of ultrasound to place central lines. Journal of Critical Care 2002;17(2):126 37.
Ultrasound? Since when? CDC (2002) - Use of ultrasound guidance for catheter insertion substantially reduces mechanical complications NICE (2002) - Use ultrasound guidance for catheter insertion substantially reduced mechanical complications AU CNSA (2007) Recommends use that patient safety could be improved by combining ultrasound guided puncture and ECG-guided positioning. APIC (2009) - Use ultrasound guidance for internal jugular catheter insertion. CDC/HICPAC (2011) - Use US guidance to reduce number of cannulation attempts and mechanical complications if technology is available (Level of evidence: 1B) AU ANZICS (2011) No recommendations on ultrasound guidance for CVC insertion. EPIC 3 (2013) US use may indirectly reduce the risk of infection by facilitating mechanically uncomplicated subclavian placement. SHEA (2014) - Use ultrasound guidance for internal jugular catheter insertion (quality of evidence: II)
Choice of Site The femoral site should be avoided. In a clinical trial of ICU patients randomized to femoral or subclavian lines there were: Higher rate of infectious complications (colonization and BSI combined) in femoral grp: 19.8% vs 4.5% (p <.001) Higher rate of thrombotic complications in femoral grp: 21.5% vs. 1.9% (p <.001); complete thrombosis 6% vs 0% The preferred order of preference: 1) Subclavian 2) Internal Jugular 3) Femoral Merrer J et al. 2001, Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial JAMA; 286:700-7
Special Considerations for Site Other factors to consider in site choice include: Anatomic deformity Presence of coagulopathy - Use a compressible site (e.g., IJ/AxV, not SC) Hemodialysis patients: Selection National Kidney Foundation 2006 Guidelines recommended against the use of the subclavian vein for any central line, unless use of the IJ vein is absolutely contraindicated, due to the risk of subclavian vein stenosis. If the IJ vein is chosen, use the right side to reduce risk of mechanical complications.
Other Special Considerations 1. Use antiseptic or antimicrobial-impregnated CVCs in adult patients (quality of evidence: I) 2. Use chlorhexidine-containing dressings for CVCs in patients over 2 months of age (quality of evidence: I). a. It is unclear whether there is additional benefit to using a chlorhexidine-containing dressing if daily chlorhexidine bathing is already established and vice versa. 3. Use an antiseptic-containing hub/connector cap/port protector to cover connectors (quality of evidence: I) 4. Use silver zeolite impregnated umbilical catheters in preterm infants (in countries where it is approved for use in children; quality of evidence: II) 5. Use antimicrobial locks for CVCs (quality of evidence: I) Marschall J et al ICHE July 2014, vol. 35, no. 7
Biopatch appropriate size CVC PICC HD Cleared Indication to reduce local infections, catheter-related bloodstream infections (CRBSI), and skin colonization of microorganisms commonly related to CRBSI in patients with central venous and arterial catheters
Many options available Not all antimicrobials are the same.. Not all dressing materials are the same.. Not all designs are the same..
Post Insertion Care Antimicrobial ointments do not reduce the incidence of CLABSI except HD catheters Apply a sterile dressing to the insertion site before the sterile barriers are removed. Transparent dressings are preferred to allow visualization of the site. If the insertion site is oozing, apply a gauze dressing instead of a transparent dressing. Replace dressings when the dressing becomes damp, loosened, soiled or after lifting the dressing to inspect the site.
Daily Review of Device Necessity Evaluate necessity of intravenous catheters daily with the patient care team. The care team understands and communicates the reason for the central catheter. Remove intravenous catheters as soon as possible to reduce the risk of catheter related bloodstream infections.
In Summary When does the Opportunity to be a healthcare provider become an Obligation to provide the best healthcare?